Cough, Chronic Cough, Rhinitis and Sinusitis - a Primer for Patients, Physician Assistants, Nurse Clinicians AND Physicians
1) In medical school and in post-graduate medical education, the respiratory tract is divided into two distinct sections and taught separately, by different departments. The upper airway is (by and large) the teaching province of ear, nose and throat physicians (ENT physicians, known formally as otolaryngologists). All ENT physicians are surgeons and they either comprise their own department in hospitals and medical schools, or function as a division of the Department of Surgery. Common conditions taught and managed by the ENT department include infections of the upper airway (e.g., rhinitis; sinusitis; epiglottitis, particularly in children), head and neck cancers (including cancers of the upper airway), acute and chronic ear infections, hearing disorders, and various causes of epistaxis (nose bleeding).
The lower airway comprises the lungs, and this important subject is taught by the pulmonary department. Doctors in the pulmonary department are NOT surgeons, and administratively are part of the Department of Medicine in medical schools and hospitals (and thus separate from the ENT department). Thus two completely different departments teach different ends of the same system, to students and post-graduate physicians.
ENT and pulmonary doctors see some of the same patient problems (mainly chronic cough), but basically their practices are very different. ENT (otolaryngology) is surgically oriented, whereas pulmonary medicine is 'medically' oriented. As far as the respiratory tract is concerned, the teaching of these two departments is not (usually) coordinated. For example, medical students may learn about the lungs in October from one group of physicians, and about the upper airway the following May from a different group of physicians (or vice versa). It would be rare for the 'respiratory tract' to be taught by both departments in one coordinated course.
In this context, the respiratory system is like a vital river that goes through two countries; there may be two jurisdictions, but it is still one continous river, whose water flow is oblivious to the ruling government. Just as nature created the river irrespective of political boundaries, the respiratory system is one continuous tract regardless of how academic departments divide it up. If you learn only about parts of the river from the two governments, each with a different perspective, you may not get a comprehensive (or accurate) understanding of the river.
Unique among bodily systems, gravity plays a major role in the respiratory system. If something happens in the upper airway - such as infection or allergy - it can affect the lower airway, due to gravity. Bacteria or mucus at the top can literally drop into the lungs. Amazingly, this simple fact is NOT emphasized in medical school or in post-graduate training programs.
2) A second problem is that teaching is usually based on disease, and not on symptoms. Taught are the classical signs of sinusitis: facial pain, headache, fever, etc. Not taught is the fact that much of the time, particularly in patients with chronic sinusitis, these 'typical' signs are not present! As a result, if the patient doesn't have obvious signs and symptoms of chronic sinusitis, it can be missed as a cause of chronic cough.
3) A third problem is lack of emphasis on obtaining a detailed medical history. That skill is simply not taught well in medical school (for a detailed discussion of this problem, see Medical History-taking in the Modern Era.) I have seen numerous patients referred for chronic cough to 'rule out asthma.' A detailed history made it apparent that the patient did not have asthma, that their cough was due to upper airway inflammation and post nasal drip.
As a result of these three 'education deficits', medical students, doctors-in-training, and practicing clinicians are usually not taught to make the connection between the upper and lower airway systems, i.e., that the two systems are part of one tract, and that what happens in the uppermost parts (sinuses and nose) can affect parts lower down (the throat, larynx, lungs) through simple gravity. While this may seem obvious (because of the biased way I am presenting the argument), in fact the connection in clinical medicine is all too often missed.